1:1 Intake Form
Please answer all questions below
Name
*
First Name
Last Name
Phone Number
*
E-mail
*
example@example.com
Date of Birth
*
-
Month
-
Day
Year
Date
How often do you practice yoga?
How long have you been practicing yoga?
How satisfied are you with your yoga practice?
Please Select
Very
Somewhat
Not at All
What could be done to improve your practice?
What would you like to focus on during our 1:1 time?
What do you hope to get out of our 1:1 session?
How do you feel about being assisted and adjusted during yoga?
Do you use yoga props?
Do you feel a connection between your mind and body when you practice yoga?
What is most important to you?
Please Select
Strength
Stamina
Flexibility
Mental Clarity
Pain Relief
Do you do any other form of exercise?
Are you open to live feedback from me about your progress?
Do you have any hobbies or things you enjoy outside of work?
What is one cool thing about you?
Anything else you’d like for me to know?
My Products
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PRIVATE SESSION
60 MINUTE Private Instruction
$
100.00
Quantity
1
2
3
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6
7
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9
10
5-Session Pack
$
500.00
Quantity
1
2
3
4
5
6
7
8
9
10
10-Session Pack
$
900.00
Quantity
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2
3
4
5
6
7
8
9
10
Credit Card Details
First Name
Last Name
Credit Card Number
Security Code
Card Expiration
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